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Central Valley Health Policy Institute

Why CAUSE is Different From the Other Health Plans

  • Because the CAUSE approach is implemented over 15 years, it allows time for the training of enough primary care physicians to provide care to the newly insured. Having primary care physicians for all will enhance prevention and enhance coordination of care that the modified Medicare Parts 1 and 2 will offer. Therefore, patients are given more than an insurance card, they are given REAL access to good care.
  • CAUSE is affordable. The costs for transitioning to universal access to basic health care is spread over 15 years. We begin by insuring children with Medicare 1 and 2, yet allow parents and the employers the opportunity to purchase private alternatives. The funding source, such as a financial transaction tax, provides an immediate means of paying for this first phase. The long implementation also gives time necessary for the cost saving aspects of the plan to be realized. These include practicing evidenced based medicine, health information technology, promoting health and disease prevention and lowering administrative costs. In years 6-10 of implementation, based on cost information gleaned from the previous 5 years, state boards can be made to work within budgets.
  • Career choice is no longer dependent on maintaining health benefits, and this helps employees.
  • The delivery of care to patients is improved by letting them go to their own physician for care whether injured at work, home, or in a car.
  • CAUSE provides universal coverage by building on a Medicare system that is currently operational, with low administrative costs, and high acceptability among the U.S. population.It is not a single payer plan. It preserves a role for the private insurance companies by allowing individuals and employers to buy supplemental private policies to cover deductibles and other out of pocket costs for Medicare 1 and 2. There is also a choice for patients to buy a supplemental policy for services not covered by CAUSE. Individuals and employers can also purchase a private alternative to Medicare for All even when fully implemented.
  • CAUSE addresses the impending financial crisis of Medicare by containing cost increases through budgeting, improving prevention of disease and coordination of care with a strong primary care delivery system, broadening the pool of patients paying into and using the system, and by changing fees and payments to support services proven to make people healthier.
  • CAUSE addresses variations across the country in health care resources and access to quality care by tying Medcaid reimbursement rates to Medicare and increasing Federal Medicaid matching to the poorest sub-state regions.

Insurance Market Reforms

Reforms will be made to the insurance market in three ways. First, the qualifying private plans would not be able to deny children coverage due to health status. Private wraparound plans for adults who buy into the CAUSE plan Part B would not be able to deny coverage due to health status. Lastly, community-based premiums will be charged for children in wraparound plans. This will make more readily available a higher quality of insurance, especially to those most in need of high-quality, private health care plans.

An important part of continuity of care and promotion of health is ensuring that patients stay on their prescribed medications even when they change insurance coverage. CAUSE will, without exception, cover a patient’s medical regimen even when the patient changes his or her health care insurance plan or coverage. The choice of medical regimen will be determined by the physician and patient.

Administrative Modifications

The CAUSE approach will be administered through a national health board that serves as a center for medical effectiveness. It will consist of clinicians, researchers, hospital administrators, business community members, health care managers and economists, nurses, health insurance and managed care organization representatives, consumer groups, patient representatives, public health experts, pharmacists versed on the effectiveness of medications and the costs of drug development, and health policy scholars. Providing a large range of experts will guarantee that all sides of every health issue are looked at carefully and that the best solution or solutions are always made. National health board members will be chosen by the president and confirmed by the Senate for at least 10-year terms so as to exceed the tenure of any single presidential administration and ensure continuity in policy.

There will be many other important functions of the national health board. One will be to help produce and publicize information that promotes the adoption of clinically based medicine and establishes incentives for best practices. Targeted funding will be provided through the Agency for Healthcare Research and Quality (AHRQ) and the National Institutes of Health (NIH) for research which will evaluate new and existing medical treatments and devices on their effectiveness in making our society healthier. Researchers will include health policy experts at academic centers, independent research staffs, and private pharmaceutical or biotechnology companies. A team of research analysts employed by the board will investigate the cost-effectiveness and value of certain medical tests and treatments. The team will also make recommendations regarding what drugs and procedures ought to be covered based on demonstrated effectiveness.

Funding from the board will allow for hospitals and physicians to coordinate appropriate pilot programs, while eliminating co-pays for those procedures or tests that are most effective and increasing co-pays for treatment options found inconsistent with evidence-based medical management. Funding would come from 0.05 percent of projected CAUSE spending from the Medicare Hospital Insurance Trust Fund, 0.05 percent of the projected Medicaid spending from general revenues, and an assessment of 0.05 percent of private insurance premiums. The national health board would also alter reimbursements for physicians by increasing payments for services that result in better health outcomes and have historically been poorly reimbursed, including but not limited to prevention, diagnosis, coordination of care, and following evidenced-based medicine. It will also reduce physician payments for procedures and tests that are not thought to improve health outcomes or quality of life.

There will be at least one elected and appointed health board for each state; states with larger populations could have sub-state regional elected and appointed health boards to keep health care uniquely formed for the specific needs of any given population or special needs due to region. Board membership selection would be designed to ensure that all stakeholders are represented. This would allow the different health needs and patient populations of each state and sub-state region to communicate needs and policies to the national health board.

State and sub-state boards will monitor CAUSE costs and develop plans for increasing effectiveness and efficiency of CAUSE delivery. The national health board and state health boards will also work with the present Medicare intermediaries in administering the new approach. Public health issues, credentialing and licensure, formularies, malpractice, and safety forums remain under state jurisdiction. State and sub-state boards will also provide a public forum for debate and public input on issues such as ethics, value purchasing, and coverage.

Modifications to Current Medicare Healthcare Delivery

Much of the present Medicare and health care delivery framework will remain intact. Some adjustments will be made to areas such as payments. Payments to providers will be a combination of fee-for-service, salary, and capitation to the variety of health delivery systems that we presently have. Fee schedules will be altered to pay more for cognitive services and procedures shown to be of benefit, and less for procedures deemed marginally useful for enhancement of health. Payment for identical services will be uniform regardless of physician specialty. The Federal Medical Assistance Program (FMAP) will be changed to provide supplemental federal funding to large sub-state areas with populations of 500,000 people or more that are poorer than the state averages. This will successfully increase access to health care and enhance the quality of care. Fee-for-service payments for procedures and services should be nationally uniform, with adjustments for differences in cost of living. Additional adjustments based on population health and health care system features will be made into fee-for-service rates. Similar factors will be considered in establishing local area costs as a basis for negotiating organized delivery system rates.

Modifications to Promote Health

The educational system as well as public policy will be utilized to encourage healthy habits in schools and neighborhoods. This will work in prevention, helping attend to habits that contribute to poor health, which in turn will create a generally healthier nation. Ideas like nutrition becoming a part of the elementary and secondary school curriculum, junk food and soda being banned in schools, and having education on lifelong physical activity implemented in schools would help promote prevention from an early age.

To promote health, the reform will encourage utilizing the employer/employee connection in health care. Tax credits will be given to employers to offer programs that enhance health of employees in areas such as exercise, weight loss, and healthy food options. Good health practices such as blood sugar measurement, hemoglobin A1C, blood pressure, cholesterol level, weight, body mass index, and smoking cessation will be rewarded.

If patients meet benchmarks, they could receive rebates or they could be eligible for lower insurance premiums from employers or through CAUSE. The tax code would be amended to allow employees to use flexible spending accounts for specified programs that reward good health practices. The Health Insurance Portability and Accountability Act (HIPPA) would be amended to mandate that all insurance plans are exempt from deductibles as preventive services. This would be recommended and regulated by the national health board with input from the regional boards. To fund such programs, the federal government will increase the federal excise tax on cigarettes to $5.39, with a proportional increase in the taxes on other tobacco products.

To further promote health, primary care and care coordination will be strengthened. Strengthening strategies will include offering financial incentives for medical school graduates to enter primary care specialties and remuneration for cognitive services will be increased relative to procedures. Quality and efficiency-based economic incentives will be offered for physicians who provide patients a medical home as their primary care physician. Additional providers will be trained to accommodate the repeal of the freeze on postgraduate training programs. Training will be modified to encourage primary care; incentives will be provided in the form of pay and a cut in medical school expenses.

Establishment of Systems that Improve the Use of Information

A Health Information Technology (HIT) program will be promoted by CAUSE. This will consist of the federal government levying a 1 percent tax on private insurance premiums and spending 1 percent of CAUSE expenditures for HIT. There could also be matching funds with the states to provide capital assistance to providers as they begin to adopt the HIT program. Federal matching funds with the states will help to develop health information exchange networks. Advancing health information through technology will help health care providers provide the best treatment possible in a more direct and efficient way.

Medical Mal-Practice Policies

CAUSE would require malpractice law reform nationally in order to reduce the costs of malpractice insurance for providers. Under CAUSE, an individual who files a malpractice claim in state court should have the facts of the case reviewed by a panel chosen in consultation with the state health boards that consists of not less than one qualified medical expert, a physician whose specialty is appropriate to the case, a community representative, and a legal expert. The panel will review the facts of the case to verify that a malpractice claim exists. There would be a presumption of reasonableness if the health care provider demonstrates adherence to the accepted evidence-based and clinical practice guidelines established by the national health board. Using the panel findings, the individual will have the option to engage in non-binding mediation prior to filing an action in court. There would be sanctions against attorneys who file frivolous malpractice claims in court.